INVESTMENT PROVIDER APPLICATION

INVESTMENT PROVIDER APPLICATION
Please complete this information prior to referring investors. This application will be used to assist our compliance team in understanding the nature of the investment and to determine administrative necessities.
ISSUER INFORMATION
COMPANY*
EIN*
Address*

MAILING ADDRESS

Street Address Line 2

CITY, STATE, ZIPState / Province

Postal / Zip Code
YEAR FOUNDED
WEBSITE*
PRINCIPAL/OWNER NAME(S)*
EMAIL ADDRESS*
MAIN POINT OF CONTACT(S)
CONTACT NAME #1*
EMAIL ADDRESS*
example@example.com
Would you like to add another point of contact?*

YesNo
CONTACT NAME #2
CONTACT NAME #2
EMAIL ADDRESS
example@example.com
Would you like to add another point of contact?

YesNo
CONTACT NAME #3
CONTACT NAME #3
EMAIL ADDRESS
example@example.com
Would you like to add another point of contact?

YesNo
CONTACT NAME #4
CONTACT NAME #4
EMAIL ADDRESS
example@example.com
DIRECT PHONE NUMBER*
INVESTMENT INFORMATION
OFFERING TYPE*
DESCRIPTION
INVESTMENT NAME*
KEY DATES/DEADLINES IF ANY

MonthDayYear
Date
INVESTOR CAPITAL CURRENTLY MANAGED
PRINCIPAL EXPERIENCE
HOW MANY MONTHS DO INVESTORS TYPICALLY HOLD THIS INVESTMENT?
CAN THE INVESTOR EXPECT TO MAKE ADDITIONAL CAPITAL CALLS?
EXPECTED INVESTMENT AMOUNT
MINIMUM DOLLAR AMOUNT TO INVEST*
ARE INCOME PAYMENTS EXPECTED FROM THIS INVESTMENT?
IF YES, WHAT IS THE FREQUENCY?
IS A STATEMENT PROVIDED TO THE INVESTOR?
IF YES, HOW FREQUENTLY AND BY WHAT DELIVERY METHOD?
CAN INVESTORS EASILY REQUEST WITHDRAWALS?
ACCREDITED/NONACCREDITED INVESTORS?*
Monitoring Fee Questionnaire
Name on Card*

First NameLast Name
CC #
Zip Code
EXP Date
Code on the back
ACKNOWLEDGEMENTS AND SIGNATURE
1. Investment provider agrees to register ownership of the investment to “IRA Club FBO (Client Name) IRA (Client Account Number 2. Investment provider understands that the EIN for all IRA Club investments held in the IRA accounts is 20 5332361. The IRA investors’ SSN should not be used for reporting retirement account investment purposes. 3. Investment provider agrees to issue all payments, income, dividends, distributions and/or payoffs directly to IRA Club. Funds are not to be sent directly to the client’s personal accounts. 4. Investment provider understands that IRA Club does not perform any due diligence on this (or any) investment and understands that IRA Club does not endorse investments. 5. Investment provider agrees to provide IRA Club with an annual valuation as required by the IRS. 6. Investment provider agrees to provide IRA Club with evidence of ownership of each investment including stock certificates or other written communication. 7. Investment provider acknowledges that IRAs are restricted from making mandatory capital calls if the capital call results in a prohibited transaction. Any additional investment will be done so on the account holder’s discretion. 8. Investment provider agrees to inform IRA Club if they become aware of any prohibited transaction as defined in IRC 4975. 9. Investment provider agrees to notify IRA Club of any changes in address, phone, email or company status. 10. Investment provider understands that IRA Club does not promote, sell or distribute any investment, including the investment described in this document. Additionally, IRA Club does not provide tax, investment or legal advice to any party including the issuer and/or the IRA account owners. The investment provider understands that IRA Club is a self-directed IRA administrator and is not an investor. 11. Investment provider agrees to not make any representations to any party that may contradict language in this document.
PRINT NAME*
TITLE*
PHONE*
EMAIL*
example@example.com
Date

MonthDayYear
Date
Type a question

Clear
Should be Empty:

INVESTMENT PROVIDER APPLICATION

ISSUER INFORMATION

MAIN POINT OF CONTACT(S)

INVESTMENT INFORMATION

Monitoring Fee Questionnaire

ACKNOWLEDGEMENTS AND SIGNATURE